Russia mental health service reform: learning about 'home' from providing technical assistance 'abroad'

Aldred H. Neufeldt, John A. Toews & Svetlana Shklarov

Abstract

Transformation of a hierarchical hospital-based to a personalized community-based mental health services system was the vision guiding a 10-year series of Canada-Russia technical assistance projects. Strategies included training for regional leaders organized as 'communities of learners', pilot projects, study tours, and visibility to innovations at conferences and through publications. Critical analysis of experience identified five key lessons for development of quality services. 1. The concept of 'community' is more complex than often thought, requiring translation in a variety of ways to fit different cultures. 2. Cultural, legal and economic values of countries are amongst the strongest influencers on how human services are organized, contributing to a rich diversity of forms even when goals are similar. 3. Philosophies and knowledge about human services are bigger than legal and cultural values, and can be successfully transmitted. 4. Complexity increases as services shift from hospital-based to differentiated community-based systems, requiring a shift in nature of fiscal and service quality controls from centrally managed mechanisms to strategies embracing the complexity of services required for diverse human needs. 5. Old knowledge is discarded at some risk to future human welfare.

Introduction

A paradoxical outcome from providing technical assistance often is that participants learn as much about their 'home' context as it affects both services provided and the people involved as they do of the situation 'abroad'. This paper provides a reflective analysis of learning that accrued from technical assistance in support of the reform of Russia's mental health services through a series of collaborative Canada-Russia projects beginning in 1997.

The broad context is set out elsewhere in this issue (Gurovich & Neufeldt, 2007; Gurovich, 2007). Briefly, in the early 1990s the Russian Federation was beginning to reform its hospital-centered, illness treatment approach to psychiatric services by phasing down the number of beds in large psychiatric hospitals, beginning to extend mental health services beyond the traditional structures, and encouraging the adoption of 'poli-professional teams', i.e. the addition of psychologists and social workers to the staff complement. This was occurring as Russia's economic system was being transformed from a centrally planned to a market driven approach (perestroika), and the broader healthcare system was beginning to be reformed from an integrated, hierarchical model to a more decentralized, insurance-based approach (Tompson, 2007). A painful part of the transformation involved collapse of the economy for several years during which government funding for existing services was sharply curtailed. This resulted in hardships for patients and professionals alike. Basic living conditions in psychiatric hospitals were poor, funding for medication inadequate and salaries of staff unpaid for months at a time.

These issues dominated the context when our collaboration began, and one might think they would discourage interest in a process of reform. The reverse proved to be true. Even though there were no financial incentives for participation in our first teaching/learning events (indeed, there was a cost to local budgets in that participants had to pay their own travel and accommodation costs), a high degree of interest was shown by psychiatric service leaders from across Russia, with each 'community of learners' participating in a series of training-the-trainer events over-subscribed. The main challenge addressed by the collaboration was to transform long-standing ideas and habits associated with more than 70 years of emphasis on large psychiatric hospitals as central to and the main resource for diagnosis and treatment.

Russia has long had a large number of well-educated psychiatrists. Their dominant orientation when we began was towards hospital-based biological treatment, though they also had a social view of their role including experience with making home visits. Nurses and other staff in hospitals had support roles only. Psychologists, then recently added, were few in number and often had little prior experience with clinical services. Social work was a new profession with a scope of practice principally thought of as completing paperwork for inpatients in preparation for release from hospital such as replacing lost citizenship papers, gaining access to housing when their rights to accommodation had been lost due to unscrupulous practices and so on. And, there was only the possibility of a family led consumer organization at the beginning.

In this context Canada's experience with community-based mental health services dating back to the 1950s (e.g. Lawson, 1957; Canada, 2006) was seen as a model that had relevance to Russia. It didn't escape notice that both were large northern countries with a mix of densely and very lightly populated areas. Since we were from Calgary, our primary reference point for the exchanges that followed was the Alberta context, though reference was made to developments elsewhere.

In the following sections we briefly describe the approach to technical assistance, and then present our analyses. Of necessity, much of the evidence is based on an accumulation of observations over time rather than on systematic data collection, though some of the latter was done. To limit the risk of erroneous conclusions based on incomplete information (Type 1 error) or risk from personal biases (Type 2 error), observations are presented only if independently arrived at by the authors on a number of occasions, in different locations, involving different sources of information. Such observations were assessed against a framework of accumulated knowledge based on some 40 years experience with and research on transformation of mental health and other similar services (e.g. Neufeldt, 1971, 2004).

Technical Assistance Approaches

Summary descriptions of the three projects undertaken are provided elsewhere (see URL: www.crds.org/regional/russia/index.html). The first project had two major objectives: to introduce basic concepts of community-based mental health rehabilitation to a cohort of lead psychiatrists organized as a 'Community of Learners' (COL) in a series of 4 two-week long workshops led by both Canadian and Russian experts; and, to develop a draft curriculum for training of social workers in the psychiatric services environment. A COL of 20 individuals was planned, but interest was such that 48 from across Russia participated, all paying their own travel and accommodation costs. Following a 'training the trainer' strategy, most transferred ideas gained to their home hospitals, many experimenting with psycho-education groups, and a few supported patient self-help groups-- both novel initiatives at the time.

The second project repeated the COL approach, this time involving 35 psychiatrists, psychologists and social workers, along with a few family members, from 24 cities and regions. A particular sub-objective was for participants to develop small-scale demonstration models experimenting with psycho-social rehabilitation approaches and in engaging the involvement of patients and family members in their processes. By the end of the second project a sizable number of hospitals had developed psycho-education groups for a variety of purposes (some for staff education, some for inpatients or family members), a few were experimenting with supported housing options where unused facilities on hospital grounds were turned into semi-independent living quarters, and one had managed to negotiate a mutual support arrangement between a Dispensary and a 'social service centre' so that people with psychiatric impairments could access daily living support. The latter is particularly noteworthy in that it bridged barriers of legislation and stigma between two deeply entrenched health and social services systems. Perhaps most notable was that Russia's first mental health advocacy organization had been formed, the all-Russia society of family members of people with psychiatric impairments (New Choices).

The third project was much more ambitious, taking the form of a 'Mental Health Stream' within a cross-disability Canada-Russia Disability Program. Special attention was given to selected regions that had demonstrated interest in piloting new approaches to service for people with disabilities. The Mental Health Stream focused on 6 sites in three main regions - 4 in Central Russia (Moscow, Ryazan, St. Petersburg & Tambov) and 1 each in the North Caucusus (Stavropol) and West Siberia (Omsk). In three of these (Moscow, Omsk and Stavropol), cross-disability initiatives supplemented and reinforced mental health stream activities, particularly those of the Social Work Stream which worked closely with universities to develop and introduce a social work curriculum consistent with European intent to harmonize university professional education by 2010 as expressed in a 1999 Bologna declaration signed by 29 Ministers of Education (see URL: ). A related focus was to support the strengthening New Choices both at federal and regional levels. Each participating region experimented with application of bio-psycho-social principles within the 'recovery model' of mental disorder, introducing what for them were new service models to prevent hospital admission, improve in-hospital treatment and service, and support individuals on leaving hospital. Project activities supporting these initiatives included 2 COL cohorts that expanded upon previous training involving 116 psychiatrist, social work, psychology, nurse and consumer leaders from 32 regions (76 from pilot regions); provision of consultation to and training at the pilot regions by Canadian and Russian experts; study tours to Canada by 33 Russian professional, government and consumer leaders; and extensive in-service education initiated by graduates of the COL programs, some supported by Canadian experts.

Early participants were mostly senior psychiatrists, with a few social workers and family members. The composition of participants in succeeding projects gradually changed towards more junior psychiatrists and increasing numbers of family members and personnel with backgrounds in psychology, social work and nursing and others.

The cumulative effect has been substantive. A closing evaluation noted that a paradigm shift has taken place with adoption of a bio-psycho-social approaches to treatment, acceptance of a 'recovery model' guiding thought, the inclusion of both families and people with mental disorders as active partners in planning at all levels, and so on. The tangible result has been development of a sizable number of model programs. As these programs proved themselves, their effectiveness was documented (often through doctoral dissertation research), with results disseminated through both journal publications and conference presentations arranged by Moscow Research Institute of Psychiatry (MRIP). These include Russia's first clinics for early psychotic episode, models of supported community housing, psychosocial rehabilitation programs, assertive community treatment, and others. Further, the fledgling self-advocacy organization has grown from 1 to 47 chapters, and their value as part of policy and program development has come to be recognized in all demonstration regions.

Reflective analysis

Of the sizable number of observations that might be made on learning that accrued from the technical assistance process, the following stand out as having relevance both for the understanding of human services in our own environment and for pursuit of future services elsewhere.

1. "Community" is not "Collective"

The word "community" is closely identified with current mental health and other forms of human service in Canada and elsewhere. One of our first lessons was in how imprecisely the word is used in the English language (services are "community-based", the "community" is involved in planning, etc.) leaving its meaning non-specific and, hence, difficult to translate into a language based on words with greater specificity of meaning.

Most if not all of us involved with the Canada-Russia partnership in the mid-1990s began with what, in retrospect, was a naive assumption - that the notion of 'community' should be readily understood in a country that is noted for having adopted the 'collective' as a way of organizing much of its activity. Even though we knew that such collectives had been far from perfect, it came as a surprise that no sense of 'community' in any of the ways we think of it was attached to the word. Meanings of the word 'collective' were strongly associated with a form of official organization and of state control rather than of shared identity, with a distinctly negative connotation. As to the word 'community', there was no Russian word in common use at that time embodying any of the meanings we attach to it. The closest was one word 'obsheena', but it had been identified with 'religious communities' and in an environment frowning on religion the term had largely become archaic. Another word 'so-obshestvo' had never been used to signify the western notion of community but seemed close enough to suit some of our purposes.

Since our task was to introduce concepts and approaches associated with 'community-based' mental health services (as contrasted with the hospital-centered services with which Russia was familiar), we needed to introduce the notion of 'community' in a way that freed it from our cultural biases. A part of the solution was to adopt 'so-obshestvo' as the general term meaning an association or group of people doing something together, thereby giving it broader meaning. This usage has subsequently become widespread. More importantly, we deconstructed the different ways in which the term 'community' is used in North America, since each of these conceivably could be translated in a different way into Russian. For instance, use of 'community' to denote geographic area is quite different from one which denotes community as the 'the place where people normally live and work' (contrasted with life in residential institutions) or community as 'involvement of ordinary people in decision-making' (when contrasted with professional or government decision makers), or community as 'a group of people with a common identity and shared experience' such as an 'ethnic community' and so on.

Making these distinctions was essential to the translation process, but it also served the additional purpose of sharpening these different dimensions of what it means to be 'community'. It could be argued, that so doing is important for the future well being of services in Canada and elsewhere. Each distinctive way of using 'community' adds an important dimension to how one thinks about community-based human services, the meanings of which are at risk of being lost on successive generations unless care is taken to articulate them.

2. Cultural, political and economic values are the biggest influencers in how human services systems are organized

A second observation arose from a contrast in how services had evolved in our respective countries; namely, the powerful role that cultural, political and economic assumptions and values have in influencing the shape and nature of human services. In an era that emphasizes 'evidence-based' decision-making (no less so in Russia than in North America) it has become somewhat impolitic to recognize the role of values.

That there are differences between countries (or even between regions within countries) in how human services are organized is well known. When contrasting services, say, of North American with West European countries, one readily notes that some are premised on the notion that "governments know best" what kinds of services should be offered to its citizens, others that "individual citizens know best" and one should be wary of too much government involvement; some that health services should be publicly funded, others that private funding is important; some that 'individual rights' are the most important, others that 'collective rights' are more important than individual citizens' wishes, and so on. Despite such differences, there also has developed a substantial overlap in how services are conceived, the policies on which they are based, and the language used to describe them through such international organizations as the World Health Organization (WHO), the Organization for Economic Cooperation and Development (OECD) and others.

In contrasting Canada's with Russia's approaches, the differences were more marked. Though there was a common understanding of the nature of mental disorder, particularly of a severe and persistent nature, the fundamental assumptions underlying existing services had diverged markedly during the nearly 50 years of 'cold war' when there was very little opportunity for information exchange between Eastern Europe and western countries. Of course, it was recognition of such differences that prompted collaboration in the first instant.

Russia's psychiatric services, like the rest of its health care (see Tomson, 2007), had been developed around an approach characterized by centralized planning, a hierarchical model, with all facilities owned by the state and all personnel being state employees (the 'Semashko model'). There was no equivalent to the involvement of 'non-governmental organizations' (NGOs) prevalent in OECD countries. As Tomson notes, this approach to health care had been effective for preventing diseases, but was increasingly constrained in its ability to address other health issues by the late 1980s. Gurovich (this issue) makes a similar observation about the impetus for changes to psychiatric services and by the time we became involved in the mid-1990s some changes were already underway of the nature described. While some psychiatrists provided private services on a user pay basis, originally to make up for lost income during the then economic crisis, and linkages were being made to other health care streams, the traditional system remained intact with virtually all expert and financial resources tied up in large psychiatric hospitals that, in turn, might be linked to one or two dispensaries which mainly provided medication to 'outpatients'. The dominant view in Russia was that these approaches were based on the best available knowledge. To Canadian eyes this arrangement seemed to have more to do with the political, cultural and economic values of Russia's history than with 'knowledge' about how the best services might be provided as reflected by application in countries such as Australia, Britain, Canada or the USA.

Conversely, Russian leaders visiting services in Canada were struck by the differences that our particular form of governance, funding and societal values had on our services. For instance, they noted the apparent impact of 'market economy' thinking on our services (e.g. cost of psychiatrists time reimbursed on a fee-for-service basis, service purchase arrangements with not-for-profit and for-profit NGOs, etc.), systemic consequences of 'market economy' planning (e.g., shortages of service providers, problems of access to services, and lengthy waiting lists), and the seeming economic inefficiency of our decentralized networks of services. The dominant Canadian view was that these approaches were largely knowledge-based.

Our Russian colleagues also were struck by the extent to which 'consumers' were involved in services planning, a value that was foreign to their historic valuing of professional and expert leadership. Some of these directions were seen as potentially transposable to their system. When it came to what for them were novel services (such as early episode clinics, assertive community treatment, or 'community residential services'), the question was merely whether some form of these services could be adopted within the (values based) framework of their system.

In short, what the markedly different forms of service organization between Canada and Russia underlined was the importance of distinguishing between 'values' as contrasted with 'knowledge' bases of decisions about how mental health and other human services are organized. For instance, it was easy for us as Canadians to see the limitations of the service system that had been developed, and its relationship to political and economic values of communist Russia; it was not so easy to see the relationship of our own service models to market economy and other values of the Canadian context until our Russian colleagues pointed them out. The dominant inclination in both countries was to see their own way of organizing services as being heavily influenced by research based knowledge until closer examination put that into question.

Our exchanges brought into perspective the role of both 'values' and 'knowledge' in shaping mental health services. Clearly, both are important and the question becomes one of not only understanding this when one evaluates existing services or plans new ones, but being clear about the particular values one seeks to put into practice and how extant knowledge relates to such values. A lesson learned was that when both are not considered in relation to each other, significant distortions can and do occur.

3. Embracing complexity vs. controlling complexity

The contrast between Canada's and Russia's ways of organizing services also brought into relief the different kinds of complexity each approach has to deal with, and the question of how to manage such complexity.

As outlined by Gurovich (this issue), since the mid-1990s differentiation of Russia's psychiatric services has taken place in two ways. The first has been to create linkages with parallel health services (such as in sexological or suicide prevention centres, 'cabinets' in general health care community clinics, etc.) as well as services in some industrial settings, thereby beginning to approximate what would be considered 'mental health' services. The second, beginning in the late-1990s, has been to diversify the number and kinds of services available within the psychiatric service system itself (i.e. hospitals and dispensaries) such as adoption of psychosocial rehabilitation approaches and testing of new service models that emerged as part of the Canada-Russia partnership. The net result has been to increase the number of options available to service users, but it also has increased the complexity of services to be coordinated.

The particular way in which Russia's psychiatric services are seeking to manage such complexity could be described as 'controlled' in that it seeks to keep new services closely linked to the existing services. This happens in two main ways. First, central government authorities (at federal and regional levels) directly approve all new service forms and organizational arrangements before they are widely adopted. Such approval is vital for funding, even if this involves only internal budget reallocation. Second, such diversification as occurs takes place within a context that is familiar. For example, arrangements made by the psychiatric services system with other organizational structures are rooted in the same history of central planning and hierarchical control; hence, the relationship is that of linking parallel structures. The expansion of options with the psychiatric service system itself essentially involves internal reorganization.

This 'control' strategy of managing increased complexity of services is eminently rational for its stage of development, and reminiscent of Canadian approaches to service coordination in the 1970s through the 1980s when provincial governments were still heavily involved in directly providing psychiatric services. Since few services in Russia at this time are provided by voluntary or private sector organizations (private psychiatrists largely operate outside the system), the overall complexity is quite limited.

What remains to be seen is how long such a 'control' approach can be sustained. If the Canadian experience is any indicator, one might expect that limits will be encountered as services become even more differentiated. Then the question of interest to outside observers will be whether and how changes will be made to managing the increasing complexity, given the values underlying Russia's services systems.

The Canadian experience is instructive in this regard. By the mid-1990s it was apparent to critical observers that a controlled approach to managing complexity was becoming increasingly difficult. This was a time when increasing emphasis was being placed on: (a) involving people affected directly by a psychiatric impairment in planning for the delivery of services and on 'disability rights'; (b) problems of a 'mental health' nature as varying immensely both in degree of impact on ability to function appropriately in day to day lives and in the nature and intensity of services required; (c) services as a continuum from informal supports that are easily accessible and near to where a person spends her or his daily life, to those that are most formal and specialized; and, (d) prevention and early intervention within the emerging idea of a 'recovery model'. As this happened, services became increasingly differentiated with new and different kinds developed by a growing number of consumer groups, NGOs and the newly developing regional health authorities.

The resulting complexity placed growing strain on existing 'control' mechanisms that sought to assure reasonable equivalence of service across a given province, keep costs of services down, and so on. For these and other reasons most provinces in Canada decided to decentralize responsibility for managing health services (including mental health) to regions. In turn, such decentralization opened the possibility for regions to adapt services even more to better meet the particular population needs of their area, and for central (provincial) governments to focus more on establishing service standards and monitoring the use to which allocated budgets are put. The net result has been the development of an exceedingly complex network of services - one that might be characterized more of a 'web' than a 'hierarchy'. With such increased complexity old control mechanisms no longer work, and new ways need to be found to embrace it.

For example, by 2005 the Calgary Health Region (CHR) served a population of 1.18 million through a dedicated system of nearly 90 services, funded an additional 50 community service agencies in whole or part, and worked closely with programs and services funded from other sources such as Seniors Health, Child and Women's Health, Home Care, and a variety of social services and housing agencies. These services are organized along two dimensions: (1) age-related clinical populations of Child and Adolescent, Adult, Geriatric and Forensic; and, (2) a spectrum of services or 'continuum of care' from prevention and promotion through to rehabilitation and support (see Table 1).

Table 1
Examples of Calgary's continuum of mental health services clustered according to its prevention focus

Negotiating a complex system such as this can be daunting, especially for people with mental illness. Yet, it is difficult to see whether any services could be omitted. Indeed, it is our opinion that all these services are necessary. If one segment of care is not provided the whole system fails. For example, if accommodation is not available in the community, inpatient services cannot function optimally nor can 'crisis' or 'rehabilitative' services. It is our observation that this complexity of services is required to allow for the range of needs that people have. Further, it is our view that services should not be wholly run by one organization such as the CHR. Communities themselves must be involved in owning the issues, providing the services and advocating for people with mentally illness. In this respect the voluntary, non-governmental sector makes a major contribution whether it is through advocacy or through educational services. Both contribute to early treatment and help decrease stigma. Self-help is as crucial as care. As a way of helping people negotiate through this complexity, a special service titled 'Access Mental Health' was developed to provide a ready source of information and referral to individuals or families in need of specific resources. Other new forms of service are in their infancy to help navigate through the complexity.

Indeed, if individuals are to receive the kinds of supports and services needed, while at the same time encouraging self-help, then at least this degree of complexity in services system seems to be needed and any attempts to oversimplify may not do justice to the diversity of issues faced by individual service users. That said, it remains a question whether one simply embraces such complexity and trusts in-built control mechanisms of what are essentially 'market' forces to assure that services recreate themselves in new forms to meet changing needs, or whether some form of external or internal control will be required to manage the complexity.

4. Old knowledge is discarded at some risk to future welfare

Russia has maintained a largely institutional mental health care system. In Canada, as in many other countries there has been a decreasing reliance on mental hospitals in favor of psychiatric units in general hospitals. These units rapidly discharge patients back into the community when ideally, for a small number, longer term hospitalization may be warranted.

In North America, as well as many European countries there is a growing concern about the rising prevalence of homelessness. Various studies have indicated that a sizable portion of homeless people have a mental illness that is inadequately treated if treated at all. We have not yet conceptualized how best to service this population, so they rotate through various drop in centers and other sources of housing and the streets. Other individuals in need are subject to repeated hospitalizations in general hospital units when a longer period in hospital or a sheltered living environment would seem beneficial for their well-being.

Problems associated with large residential institutions such as 'mental hospitals' have been well documented, and one should seek to avoid them. That said, it is clear their equivalent high-end community residential settings do play a role in the full spectrum of care. We have not yet adequately conceptualized and provided the full range of services required by the most disadvantaged. Russia is in a position to carefully consider the range of services required. It is just possible that the difference in values (i.e. state care vs. individual responsibility and autonomy) will dictate different approaches in each country.

Conclusions

In some respects the observations reported above has been of an 'unanticipated obvious' nature. The role of 'the unanticipated obvious' is considerably under-estimated as an influence on small and large-scale change and reform, though the notion of paradigm shift is based on this imponderable - a paradigm shift occurring when what previously wasn't understood quite suddenly becomes obvious. While we are not suggesting any 'paradigm shifts' as such, nevertheless a number of lessons were identified in contrasting Canada's with Russia's mental health systems that seem over-looked. These may be summarized as follows.

1. Services systems become increasingly complex as they shift from institutionally-based forms to a differentiated community-based system that seeks to respond to individualized needs within their community context. In turn, such changes in complexity require new responses both by those seeking services and those organizing services. Organizationally, the contrast might be likened to that of a centralized, hierarchical 'pyramid' with a limited set of linkages as compared with a 'three dimensional web' of options with a large set of possible inter-relationships of service options. For service organizers, new ways need to be found of maintaining service quality and cost efficiency. For those seeking services, new ways need to be found to navigate amongst the many possible service options so that the most individually appropriate ones are found.

2. The strongest influencers of how human services systems are organized are the cultural, legal and economic values of a country. Whatever the nature of the shift between 'institutional' to 'community' services, these will be shaped by the values of the country (or region).

3. Philosophies and knowledge regarding service organization and delivery are bigger than legal and cultural dimensions of countries. This was apparent by the ease with which basic new service ideas, as well as ideas on consumer involvement in planning, were transposed to and adapted by our Russia colleagues.

4. Even bigger are those impulses associated with basic human need. Families of people with severe mental disorders as well as service users identified with each others experiences irrespective of language, or cultural or other differences. Similarly, the perceptions of professionals as to fundamental human service needs of people with severe disorders were similar.

5. Old knowledge is discarded at some risk to future welfare. In the transition from older forms of service to newer ones, it is important not to overlook those aspects of the former services that meet basic needs of service users.

References

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Gurovich, I.Y. (2007). The Current Status of Psychiatric Services in Russia: Moving Towards Community Based Psychiatry. International J. of Disability, Community & Rehabilitation, 6 (2) [see URL: www.ijdcr.ca].

Gurovich, I.Y. & A.H. Neufeldt (2007). Collaborative Learning from Mental Health System Reform in Russia: Introduction to Special Issue. International J. of Disability, Community & Rehabilitation, 6 (2), 1 - 2 [see URL: www.ijdcr.ca].

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Neufeldt, A.H. (1971). Planning for comprehensive mental health programs. Canada's Mental Health, Monograph Supplement, Whole No. 67.

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Tompson, W. (2007). Healthcare reform in Russia: Problems and prospects. Paris: Organization for Economic Development and Cooperation (OECD), Economics Department working paper No. 538. Document: ECO/WKP(2006)66.

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Contributors:

Aldred H. Neufeldt, Professor and Director
Community Rehabilitation & Disability Studies Program
University of Calgary
Canada

Email: aneufeld@ucalgary.ca

John A. Toews, Professor
Department of Psychiatry
University of Calgary
Canada

Svetlana Shklarov, MD, PhD Candidate
Interdisciplinary Graduate Program
Community Rehabilitation and Disability Studies Program
University of Calgary
Canada

Email: shklarov@ucalgary.ca

International Journal of Disability, Community & Rehabilitation
Volume 6, No. 2
www.ijdcr.ca
ISSN 1703-3381